Lecture 14 - Problems in Pregnancy, a clinical overview

Question 1

What happens when things go wrong?

Answer 1

Small, abnormal structure, impaired spiral artery modelling - FGR, preeclampsia

Increasing foetal demand with gestation - stillbirth

Question 2

Decr

Answer 2

decreased conversion of uteroplacental arteries

Abnormal placental development/function

Release of circulating factions/materials

Altered vascular reactivity

Hypertension? Diabetes? Proteinuria? Liver/renal dysfunction?

Initial vasodilation (estrogens/placenta/corpus luteum)
Uterine arterial circulation remodels (extravillous trophoblasts)
Renin angiotensis system upregulated

Question 3

Doppler ultrasound

Answer 3

Can be used to determine the adequacy of placental development

Answer 4

FGR and PET

Question 5

FGR

Answer 5

Foetal growth restriction, foetal manifestation of placental insufficiency

Speed/pattern of growth - raises suspicion

Small baby
Small tummy
Slow weight gain compared with peers

Or

More minor abnormalities of the above PLUS evidence of placental dysfunction

Similar underlying molecular/microscopic/macroscopic placetal phenotypes in FGR as with PET

Question 6

PET

Answer 6

Preeclampsia - multi-system dysfunction, maternal manifestation of placental insufficiency

150mg/day of aspirin from 12 weeks until after birth

High RFs:
* Hypertensive during previous pregnancy
* Chronic Kidney disease
* Autoimmune diseases
* Chronic hypertension

Moderate RFs:
* Older age
* High BMI
* Family history

Similar underlying molecular/microscopic/macroscopic placetal phenotypes in PET as with FGR

Question 7

Foetal growth assessment

Answer 7

• Symphysiofundal height
• 2D ultrasound
• 3D ultrasound

Question 8

Symphysiofundal height

Answer 8

Quick
Low cost
Available everywhere
Insensitive / non-specific

Question 9

2D ultrasound

Answer 9

Takes time
Expensive
Available in hospitals
Better sensitivity
Often over-estimates

Question 10

3D ultrasound

Answer 10

Takes a lot longer
Even more expensive
Available in research
Looks at fat deposition
Not “real time”

Question 11

PLGF

Answer 11

Drops at 32 weeks

Question 12

Why predict, why not just treat?

Answer 12

No treatment once detected, must just predict it

Question 13

Potential consequences of FGR and PET on the foetus: before birth, after birth, long term, and what are the iatrogenic impacts?

Answer 13

• Stillbirth
• Preterm delivery
• NICU admission
• Neonatal death
• Infections
• Various conditions - seizures, deafness, respiratory distress, etc
• Chronic lung disease
• Cerebral palsy
• SEN - special education needs
• Cardiometabolic programming
• Prematurity
• Antenatal corticosteroid exposure

Question 14

Potential consequences of PET maternally: before/around birth and in future pregnancies

Answer 14

• Pulmonary oedema

Before/around time of birth
Pulmonary oedema
Uncontrolled hypertension 🡪 Stroke
Renal failure
Placental abruption 🡪 haemorrhage
Psychological effects

Next pregnancy
“High risk”
Repeat caesarean (morbidity)

Question 15

Iatrogenic impacts

Answer 15

Clinicians

• Prematurity
• Antenatal corticosteroids exposure (may actually be bad- alps study (extra reading))

Question 16

Antenatal corticosteroids

Answer 16

<34 weeks

Accepted as “A Good Thing”
Reductions in
Perinatal death
Respiratory distress
Intraventricular haemorrhage
Other outcomes

<34-37 weeks
Not as effective
No overall reduction in short/long term respiratory morbidity
No reduction in NICU admission/length of stay
Growing evidence of potential harm
Hypoglycaemia
Neurodevelopmental disorders

Question 17

Preventing placental dysfunction: both PET and FGR

Answer 17

Pre-pregnancy:
Weight loss

Weight loss
Smoking cessation (↓FGR)
Control of comorbidities
Have kids in your 20s
(Don’t have IVF)
Have kids close together
(Partner)

Aspirin 150mg in those ↑PET - only has an effect if used early, not once the condition has onset
Calcium/Vitamin D
Stay active, limit weight gain(?)
Tight control of hypertension
(Don’t go overdue)